E119 Patricia Sylla on taTME, surgical innovation, and SAGES presidency
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human. Dr. Patricia Sylla is a minimally invasive and colorectal surgeon at Mount Sinai Hospital in New York City. She's also a world-renowned innovator, and was the first surgeon on Earth to perform a transanal total mesorectal excision for rectal cancer. Ameer was on site - large and in charge - at the SAGES annual meeting, which as we all know, is always great. He was able to catch up with Dr. Sylla in person. As always, links are in the show notes below.
Ameer Farooq 01:10
Can you tell us a little bit about where you grew up and where you did your training?
Patricia Sylla 01:14
Sure. So I grew up in West Africa, Ivory Coast, a small country, used to be a French colony. And my father is from that country. And my mother is actually French originally. And they met when they were studying abroad and then he settled in Ivory Coast. I was actually born in France, but then moved to Africa. So I spent pretty much 15 years of my life; I left for college, but I had the unique experience of growing up there. And it was really quite an experience; I developed my love for/interest in medicine, when I was there. My mother was very active in the community in organizing, collecting supplies for Médecins Sans Frontières, and other groups that were doing especially cleft palate repair. So very early on, I was sort of in that activist efforts with my mom. And I always wanted to be - I didn't know that it was surgery - but I wanted to be in medicine. And then I was fortunate enough to be able to pursue my college education in the US, by the fact that she was an American citizen, so I was very lucky. I essentially went to Washington, DC where her family was, and I went to Georgetown. And then from Georgetown, I applied for medical school because it was clear I was on a path to medicine no matter what. And then I ended up going to Cornell; I was very attracted to big city, to life in New York City, so I couldn't pass the opportunity to go to Cornell and I spent four years there. And then I stayed in New York to do my surgical training, driven by the fact that I had a boyfriend at the time, who was an MD PhD, so we were in the long run for staying in New York. And then I did my fellowship as well waiting for him to finish. And I was very lucky to sample [a] different hospital system in New York City. That was very valuable experience. And I chose to do my colorectal fellowship at Mount Sinai Hospital, which was really the hub of innovation at the time. It was a really exciting time where I was exposed to laparoscopy, laparoscopic colectomy; it was one of the few sites doing laparoscopic colectomy back then. And so it was really an exciting time.
Ameer Farooq 03:20
That's an amazing story. And your parents were also in medicine?
Patricia Sylla 03:24
Oh, no, no, my father is a businessman, trained to run a company, a computer company, and my mother is a high school teacher, English high school teacher.
Ameer Farooq 03:34
So what was that experience like growing up in Ivory Coast? And how do you think that had an impact on you going forward? You said it kind of ignited your activist roots at a very young age. But how did that have an impact on you?
Patricia Sylla 03:48
Well, I think I had a unique experience in that I grew up in clearly a third-world country. So in the Ivory Coast and Abidjan city, where I grew up was actually relatively, pretty modernized. So I was lucky to go to a French school and really simply receive the best education there. But you're constantly exposed, obviously, to significant need. And so I think the fact that I had the opportunity to go, for example, we travelled to visit family in the US and in France. Very early on, I could tell the tremendous disparities and differences in life and in access to things. It definitely was impactful, to me, at least, seeing the contrast between the ultra rich and the ultra poor. And in terms of medical exposure, I think it was just the work that my mother did [that] really exposed the fact that the health system was really, really suffering quite a bit. The fact that even there was a need for cleft palate repair, those kids were literally rejected by their families, they were considered to be possessed, and families would reject them, so they would essentially be in the streets begging, and that's how they were able to sustain a decent life. I think being exposed to this and then three months later you go to the US and you see how people live normal, comfortable lives was quite striking. So you always live sort of on that edge in the middle, seeing that tremendous contrast and knowing that you want to help in one way or the other. It probably influenced me significantly, I think, at a young age.
Ameer Farooq 05:18
Yeah, you know, growing up, I used to go visit Pakistan all the time, where my family's from and so it certainly leaves an impact. Was it a big cultural change to go from being in the Ivory Coast growing up? I know, it sounds like you went back and forth quite often, was it a big change to then permanently shift and come to the US for college?
Patricia Sylla 05:35
It was [laughs]. I was lucky to speak a little bit of English, but I didn't really appreciate how much learning I would have to do and adapting. So very, very, very early on, I realized - my first year, I really dedicated to mastering English; I was very self-conscious about my lack of conversational skills in particular. That was really my main focus - was to really adapt to the culture as quickly as possible. So college was just perfect for that. And Georgetown was a great environment; it was very international. I had my French group, my West African group, and I had my American cohort. It was a really great way to integrate.
Ameer Farooq 06:19
You know, my dad is emigrated from Pakistan, as well, and did his training subsequently in the US and in Canada. This is totally my anecdotal experience. But I feel like if you've come and immigrated to a completely new country, it sort of makes you a little less reserved, a little more open to trying new things, challenging the status quo, you know, kind of like not being afraid to just put yourself out there. Do you think that is true for you, because you're clearly an innovator, you're someone who pushes the boundaries, tries new things, things that people have never thought about? Do you think that had an impact - the fact that you had to come to a new place and improve your language skills, be in a different environment? How do you think those two things interplay?
Patricia Sylla 07:07
I think you probably know that as well as I do, but I think it's [that] you're stimulated, you know, and forced to adapt quickly. And I think it makes me very resourceful and very resilient early on. So there's no question. I mean, you're in a different culture, I came to the US, I had family from my mother's side, but I was alone, my parents were not there. I had a brother on campus in a different university, we're not very close with. So, you have to survive, you have to adapt, and you have to really be resilient. So I think there's no question it makes you also very curious and excited. I can't tell you how exciting it was to be in the US and the opportunities that were presenting themselves were really incredible, from food types to entertainment, for sure. I was absolutely fascinated and entranced with the American culture and especially the freedoms, and the opportunities were just incredible. I think most of us coming to this different culture, you kind of embrace and then you seize the incredible opportunity that you have.
Ameer Farooq 08:05
Well, that's an amazing story. It's very inspiring, just that in of itself. But you know, as a colorectal fellow, I can't help but ask you a little bit about the genesis of taTME. And I will link to it in the show notes. But you gave this great lecture, I think, in Orlando, about the falsehoods and the truths around taTME. And you tell the story about how you developed taTME and you're really a fellow actually, when you started developing taTME. Can you tell us a little bit about the genesis of this literally revolutionary procedure came about?
Patricia Sylla 08:41
So I think it was serendipity, was really quite fortunate. I was very lucky that when my now husband and I moved to Boston, I decided to do a second fellowship in MIS, which was actually also very controversial at the time; all my colorectal mentors were, you know, "Why the heck would you do that, why don't just take a job or do something else"? And I always loved colorectal and MIS; it was always the two, I'd never really felt that there should be a distinction. It was sort of the spectrum of minimally invasive surgery, GI surgery. So after my colorectal fellowship, I chose to do an MIS fellowship and be in Boston and at MGH it happened that that year was the most incredible year in terms of surgical innovation, when it comes to the merger of surgery and endoscopy techniques. So my program director and mentor, David Rattner, was literally in the midst of this incredible movement of notes. So when I arrived, I was exposed to this incredible burst of activity in the lab, and there were proof of concept, transvaginal, cholecystectomy and animal transitioning to cadaver model. So it was a very exciting time. And so again, this was an incredible opportunity. So I came along with a different perspective. Obviously, you have a colorectal surgeon, and so they were in the lab working on transesophageal and transvaginal procedures. And I said, "Hey, when you're done with your swine cadavers, can I use them and try something transanally." So it was really exciting because I had the resources there. So very early on, there were really no issues of grant; I had those resources available. So we started off really with the experimental model proof of concept, and, as I talk about, we were very lucky that we didn't really rely on brand-new technology; we had the transanal endoscopic microsurgery platform available, which was really what helped propel it very early on. So we started working and developing the model in swine and then we moved to the cadaver model very quickly. And then the most exciting part, obviously, was that first case we were working so hard towards, you know, doing the first pilot, and the first human case. And again, this is where the world of connections and friendships really pays off. And through SAGES collaborations, Dave Rattner was very close friends with Antonio Lacy and they had done a lot of work together through societies. And I literally got a call from Antonio Lacy. I was completely starstruck when he called and he said, "I've be watching what you've been doing; I've been reviewing your videos and I need you to come and to do the first case with you, I have figured it out, I have the perfect patient, I got IRB approval, and I want you to fly up there and do what you do and we'll do it together." I mean, you can't say no to such an opportunity. So of course, I was pretty far along in my pregnancy at the time [laughs].
Ameer Farooq 11:15
Thirty-five weeks? Yeah, amazing.
Patricia Sylla 11:17
You know, so I cross checked everything with everyone, especially my husband and my OB. But Antonio Lacy's, at the time, his wife was an obstetrician at the hospital clinic of Barcelona. So I felt very confident. And so there was an incredible opportunity, because I think we were able to combine his expertise and his incredible gift, you know, he's an exceptional surgeon, very familiar with innovation. But combining with the [rehearsed], we had done over 50 cadavers sequentially, male female, we had rehearsed the technique to the point where, to me, it was just doing another procedure in the lab, but this was a patient under his guidance. And so together, we were able to replicate the exact same steps. And so it took the stress away, because we had rehearsed this so extensively. And it was really incredible. It was just the perfect way to tackle the first human case. And from there on, the story goes on. The most exciting part was that pioneers really saw the advantage immediately; it didn't take a lot of talks; it didn't take a lot of articles for people to really get it and understand, especially for rectal cancer surgery, it became sort of, you know, the Holy Grail. He like, we've been struggling for so long to achieve sphincter preservation, to not do APR for low rectal cancers. So there was such a gap there that it was a natural solution that we really had to explore. As you know, we worked very, very hard to delineate that pathway; we all became very early on, very attentive to safety, it's like, "Well, I've done 50 cadavers before I did my first case." This doesn't mean that everyone else has to do 50 cadavers before their first case. And so this was not practical. So the question was, "Well, how do we get people there?" Is it an Antonio Lacy, only who can do this procedure, or can we democratize it?" But still figure out the minimum standards and minimum skills that are required to be able to do this safely. So we spent a lot of time working there, it was very similar to POEM. So the trajectory of POEM and taTME were very similar. So we follow sort of the same pathway of safe implementation, delineating the proper steps or technique, refining it, and then really focusing on safety metrics, and then pilots. So I was more impressed by how quickly things evolved, because people really believed.
Ameer Farooq 13:32
You talk about, in that talk, the fact that you were still waiting for IRB in the US and then you got it in Spain, and you're 35 weeks pregnant, which in and of itself is amazing. So you go there, you do your first taTME with Antonio Lacy, and then you come back and you get all these very kind of nonthreatening, but very scary-kind-of emails, saying like, you went IRB shopping. What was that experience like?
Patricia Sylla 14:01
It was pretty surprising. I had had the blessing from my chair, of course, to do this surgery abroad; it was not the first time that a surgeon from MGH institution had done that. But what was unique that we didn't know is that even though Antonio Lacy had the IRB approval from his hospital, the policy was that if a surgeon from MGH was going to do a procedure, outside, especially in another country, we had to have run the story or the clinical scenario and gotten approval by our own IRB to protect essentially the surgeon doing the procedure. We were not aware of that [laughs], despite all that came out from there. So we had to walk it back pretty aggressively, and so we did it retrospectively. But I think it was a learning experience, I think for all of us, including my Chair, who was very supportive. But you know, this was obviously very delicate, but we were very confident that the regulatory process in Spain was solid. But it was one of those regulatory hurdles that you have to keep in mind before you do this kind of work.
Ameer Farooq 15:00
You were clearly very diligent and very attentive to the fact that you were not going to just implement this without having really solid experience, monitoring, safety, all those kinds of things. But it must have been frustrating at times. At several points along this journey, you would have setbacks where people would say, "Well, we don't know how safe this is." And then the meanwhile, you got the IRB so quickly in Spain, and then I think in that 11-month period while you were waiting for IRB in the US, people started doing it all over the place, like in China and many other places. So, as an innovator and someone who's trying to introduce a new technique, how do you think that we can both promote innovation, but at the same time, do it safely? Because I think that many people, especially surgeons, feel that there are a lot of hurdles that have to be overcome nowadays, to do research and to promote new techniques. How do you how do you think that we can go about introducing new techniques while still being safe?
Patricia Sylla 16:00
Actually it's a really interesting question, because every talk I give, I show the ideal framework, you know, that Liane Feldman contributed to, but this wasn't published until 2009; we were already ahead and doing this, just like POEM. I think, to us, it was common sense that we had to progress very, very carefully. And we also felt a pressure that in addition to publication in our discussion sections, and in subsequent papers, we had to lay some rules very early on. So even after the first case, my next endeavor was to collect a group of experts in the US. So we actually had a sponsored taTME course. The very first one that we hosted it was eight surgeons by special invitation, who had, essentially all what I felt were the requirements to do this procedure safely. And we really believed, "Let's do this in a controlled fashion, collect enough data to be able to then move on to the next step." But it was really mixed feelings when I started seeing all these case reports, and people emailing me telling me, "I've done it, I've watched your video, and I'm so excited, I did my first." And thank goodness, the majority of those surgeons were well known, these were pioneers who understood and had been innovators themselves and understood that they had to be very careful, most of them did it under IRB approval, so they had explained to the patient's risks of doing a novel procedure. But it wasn't like that, obviously as you know, it wasn't entirely controlled all the way. So it was a little frustrating, especially when you saw reports when there was no IRB approval. And so I think we walked it back by really very quickly having recommendations, statements, and then trying to really get people together to work on guidelines, or at least consensus agreements, among surgeons to say, well, you know, "Wait." And you've got this other force that was pushing in a direction of, "But it's really easy this is going to ..." There was a messaging that came from this of, "Everyone can do this." And we had to fight very hard to try to tone that down a little bit. And I think when surgeons got into the operating room and were not properly trained, and realized that, I was getting calls or messages to say, "I had to bail out, I couldn't do it, you know, you said it was easy." I never said it was easy. But so you have to be very careful. And especially when you have influencers, then getting on that procedure, and then sending the wrong message without data to support it, it becomes difficult to walk it back. But that's your mission, that's your goal is to really develop it in a safe way, collect the data that really allows you to move forward, and then really, very simultaneously, start working on training pathways for safe implementation. And industry plays a role in this. They were involved and very supportive from the beginning, but we felt you have to go beyond just hosting a course. Okay, because we know, even a cadaver course is not sufficient; you have to start thinking about longitudinal proctoring, longitudinal training, and sustained maintenance of those skills. So we really challenged them to say, "Try to pair them up with a proctor." It shouldn't be that you do a cadaver lab, and then six months later, you do your first case. There's gotta be some rules or some agreement, yes, you take the course with the understanding that you're going to be doing this with a proctor. So we have to work all those pieces. And you see the framework now that summarizes all those steps. But at the time, we were kind of figuring this out, looking at how other groups have done it. And I think POEM was very successful in doing this, but it was a smaller cohort of people doing this because of the skill set required. Right. And I want to come back to the mentorship and the learning part of this because I think it's very important. I think it's part of what SAGES is doing, really. There's this moment that you talk about where you had your first urethral injury and obviously all these reports started to trickle in, of something that we really hadn't seen in colorectal surgery or rectal cancer surgery, up until this point. What was that experience like? Obviously, it would have been just a devastating moment to have that happen to you. And did it change how you felt about the procedure? At any point did you think like, "Maybe we shouldn't be doing this"? How did that feel? It was nerve racking. I can't tell you how devastating the injury was at the time and subsequently, I think I realized what I think is a good approach for any surgeon, you have the several stages of grief. And there's a big one where it's just you're in shock and in a little bit of denial. I just put everything on hold and took some time to kind of breathe and work through the kinks. And I think what was really incredible is that this gave us an opportunity to really understand the procedure on another level. And we realized one of the issues with the training that we did in cadavers is that our dissection, typically in the cadavers - and I have videos and videos to show that - started above the dentate line. So we were kind of starting already at a five-centimetre margin; we never really worked our way back down towards the sphincter. How do we deal with a tumour that potentially involves sphincters, because we were on the path of, we're doing this for tumors, kind of, 5, 6, 7 centimetres from the verge. So we never worked through the transanal intersphincteric dissection, working towards converting to taTME. So this was a good opportunity to say we haven't done this before. And we have to sort of bridge that gap. And we know surgeons who do intersphincteric resection very elegantly, can we do this safely endoscopically through a platform or not? So I took a step back. And I was actually fortunate that it was around the same time that I was on maternity leave and I went to spend a couple of weeks in France. And I went to actually visit Eric Coulier was a pioneer and an expert in intersphincteric resection. And that experience was incredible. And it really also allowed me to look at that video, because I think it took me about four months to look at the video that I'd recorded. Thank God, I had the recording, but think about it - I had the recording, to go back to that video. Because first you go back and you say, "I have no idea what's going on." And part of the gap was that we hadn't really fully defined the perineal anatomy from the bottom up, it was never really documented very well. And the only evidence that we had for the perineal anatomy was from the urology literature. So we had to work our way back. And so we started collaborating, and it was wonderful to have key leaders also in Japan, and Korea, and France working collaboratively to figure this out, map it out. And then starting to review videos of these events, to say, "Oh my goodness, the rectourethral muscle is a muscle we don't talk about." I never want to train, it's not even in the colorectal textbooks. And when you do an APR, you do divide it, but you don't see it. So it was really a fascinating process that really in a way was my last stage of grief, you then record, you collect, you reflect, you identify where the problem was, and then you work to fix it. And that publication where I reached out to essentially every centre that I knew in the world doing this procedure and say, "If you had this injury, you're not the only one, please, don't be embarrassed to be open, to share those videos and this experience with us because we need to educate if this procedure is going to succeed, we need to break this injury, we need to deconstruct it and understand it." And I was really nicely surprised to see people volunteer their most painful videos, so we could really analyze them. This is before video-based assessment; we were just reviewing and seeing exactly the point where the surgeon gets into the wrong plane and goes to anteriorly. And so we could see the same pattern video after video. And we were able to map it out and really give instructions and advice on how to avoid it. It was good. I make peace with that injury because of that work.
Ameer Farooq 23:33
What's kind of amazing about that whole cycle of innovation is that in some ways, you actually went back and you looked at all this very old data from the urology literature talking about perineal prostatectomies, and they had actually described that Rector urethra muscle decades - I can't remember the first paper that you cited in your talk. But like decades, much, much longer ago, they'd already described that anatomy. And so in some ways, your innovation, where you develop this totally new technique, forces you to actually go back to these basics around anatomy and understanding what you're doing. It's quite remarkable in that whole cycle of innovation.
Patricia Sylla 24:11
It is. And when we actually went back to the colorectal literature to see has this been described very specifically, and what's the incidence of urethral injury in APR is that it is grossly underreported, because it's not captured in this quip. It's not captured in a lot of different databases. So we really didn't have a baseline to go by. So it was really difficult to reconcile that as well and say, "Well, we do APRs; we know urethral injuries occur." But no one really wants to figure out how that happened and how to correct it. So it was the work from the urologists because there was a period where they were very interested in perineal prostatectomies, so they were essentially dissecting between the rectum and prostate and having to deal with a membranous urethra. So it was really great to put it all back together, and then I realized I cannot believe we didn't think about this step when we're in a cadaver lab because we were so focused on, you start above the anal sphincter, above the anorector ring and you just kind of keep going forward from there on not thinking about those more real-world scenarios where while the tumour is a little bit lower, and you can still do intersphincteric resection, so let's work on that model.
Ameer Farooq 25:13
I could talk to you able taTME all day. This is the danger of me interviewing you is that I could talk to you about this all day. But I do really want to touch on the learning aspect of this and the mentorship aspect of this. You know, we were part of this great panel discussion, during STAGES talking about real-world variations in TME. There are so many different tools now that are available for doing rectal cancer surgery from the robot, laparoscopically, transanally - where do we go from here with taTME? I know this is a big, big, big question to answer, but from someone who really pioneered the technique, where do you see taTME fitting in our plethora of techniques and where do we go from here with taTME?
Patricia Sylla 26:00
Well, that's a great question. That's really the million dollar question. I think the ultimate goal was to bridge the gap of, we have to be able to do better for our patients than doing and recommending an APR for everybody with a tumour six centimeters or less. So I think the goal has been achieved. With taTME, we've really proven that we can do this, we think, to do it safely, especially with good patients, selection criteria. But I think what's been exciting to see is that you can also, especially when you master the robot, you can also get quite low; you may not be able to go all the way and do intersphincter resection, you have to be able to combine it with intersphincteric resection, but taTME gives you a tool to really evolve from intersphincteric resection. So in terms of training, I think we stand by our recommendation in terms of the prerequisite to do this, and we can't even have this conversation outside of the big elephant in the room, which is should you be doing any of those procedures unless you're at a high-volume centre? And that's a difficult question. It is not difficult in Europe; most of Europe, I think, is on board now. But I think in the US, we're still struggling because we don't really have a policy or guidelines that say, "You know, if you're doing less than five cases per year, you probably should be referring them out." That discussion hasn't been hard, because we don't tell surgeons what to do. But it's really the big question; we are assuming you are doing at least 15 to 20 cases per year. And we want you to have the best possible outcomes of those cases and give the best chance for patients to retain their continence, if there's a possibility to do so. So that's a big question to answer. And from there on, if you're in one of those sites, and you want to be well prepared to offer those techniques, I think the training pathway is becoming complex. There's no question, the ideal role of taTME, in my opinion, now, and we've said this for a couple years, is in a high volume centre that gets a lot of referrals of these complex tumours that have not responded to TNT, right? Because everything is about organ preservation now, but for those tumours that have not responded, and they're very low and threatening the CRM and threatening the sphincter, to at least send them for a referral to a high-volume centre that does those procedures routinely, that has the institutional experience to do this. So to answer your question is, if you're interested in this and you meet all those criteria, high-volume surgery, and I'm going to be doing a lot of those cases, and I've had the basic training requirements, transanal surgery, I'm comfortable with TME either lap/robotic, but I want to be able to enhance my skill set, you need to be trained in a place like that. So we don't have formal training pathways. I think that's the issue, if you end up being a fellow, I think the fellowship, being geared towards those places that do more taTME is one strategy, or working on sort of nonaccredited fellowships and/or training time, spending at least six months or 12 months in an institution, at the very least observing those procedures, if you can't really do procedures if you're not a fellow there. But I mean, there's pathways to do that, where you can really get the extended experience and mentorship from someone who's doing a lot of those procedures. But if you're dabbling in rectal cancer, I don't think there's a role for any approach really, but especially for taTME, in which, as you know, the learning curve is so long, and it does require a significant amount of cases to be able to get to your learning curve. Part of the whole crux of this, going sort of back to the theme of innovation is that we're sort of at this crossroads in surgery now, where for many things, there's clearly an impact of volume. And clearly, we've seen throughout the conference here at SAGES, where the high-volume experts, they do think about these problems differently. And the same for rectal cancer; it's not even just in the operating room, it's how do you even get to the operating room for rectal cancer? There almost seems to be two approaches: one is to educate people as to what they should do, and the second is to sort of say, "Well, maybe you should be sending that to a high-volume surgeon." And you know, where we're from in Canada where there's a large geographic spread, where it may be hard for patients to come there's still, certainly, debate about whether which sort of route we should go. I'm curious what your thoughts are about, should we be really getting people to come for further complex cases? What is the volume that you really need to be able to do this safely? What are your sort of thoughts about which direction we should go? I mean, I think in a place like Canada, especially if you have areas where there's not a whole lot of expertise or the expertise, I think that the concept of consolidating the expertise in one particular centre is critical. I'm a big believer in centralization. I know that that will upset a lot of people. But I really think the European models ... I'm not advocating for the state or the government to tell you which centres should be, you know, Centre of Excellence or not, but I think we all know what a centre of excellence looks like. We have data to support the outcomes being so linked to volume, it's just a fact. So putting effort in identifying those places, promoting those places, making sure that patients are in power to go to those places, resolving issues of access, I think is important. The higher the volume at those places, the more experienced they are going to be; if you can get patients there, you can then develop the expertise there. And this is where you'd have someone sponsored by the institution to go and get robotic training or taTME training. These places should have a taTME-trained surgeon, there's no question. I think every place that does more than 20 to 30 cases per year, should have a taTME-trained surgeon because even with a robot, there will be cases where you just cannot get low, especially very-high BMI male patients with low tumours not responded close to the sphincter, and the patient does not want a stoma, and is eligible for sphincter sparing, but you need that expertise. Having someone trained in taTME is extremely valuable. So it comes down to volume again, but the strategy is to try to promote and really make sure patients are aware of these centres and make sure that you spread that information. So most oncologists are not aware of these different or the subtleties in surgery. They sort of see it as black/white no surgery, it's surgery, you know, who cares how it's done. But the concept of stoma for them sometimes is not as relevant as oncologic results. But you need to educate the oncologist and radiation oncologist. Tumor boards, obviously, are critical. So on your tumour board, there should be a healthy discussion, it should be one of the boxes on the list, is this patient amenable to sphincter preservation and why? I think it should be on every tumour board review. And he could be, "Oh, I don't think so, because there's a threatened margin." That's one thing as opposed to, "It's possible, but I don't have the skill set; I can't do that; I don't do intersphincteric resection." That may be pushed to trigger a question of, "Well, should we send them to a site for consideration for sphincter-sparing surgery. That would be the ideal scenario.
Ameer Farooq 32:42
I did want to also congratulate you and you're now going to be the president elect for SAGES starting in 2023. As I was saying to you before the interview, this is actually my first SAGES meeting. We interviewed Dr. Feldman before and she was like, "You gotta come to SAGES." And I was like, "Well, I should try it." And thankfully, I was able to come this year, and I've been blown away by how enjoyable a conference it has been and what the energy level has been at SAGES. I'm curious if you have any thoughts about the hybrid format that we've had here at SAGES this year, and the fact that we're all able to get together again, were there any particular sessions that you think are worth highlighting and mentioning?
Patricia Sylla 33:22
So I'm still totally riding high on the meeting, I think it was incredible. And Vegas last year didn't have as much energy, because there were fewer people. I think it was incredible to get people and we're still missing a big international consortium. I mean, not having our Japanese colleagues and Korean colleagues and a lot of Europeans who couldn't make it. You know, it's not exactly the same spirit. But I agree with you, the energy was tremendous, people were so excited to be back together, having healthy debates in the sessions. So that was really incredible. The sessions - I thought the program was spectacular. So I was really excited about it. And especially with SAGES embracing more technology-focused sessions within content, there's a big push towards really understanding digital surgery, being at the forefront of AI innovations, and it fits right in our mission of innovation. We had a couple of sessions on AI - that was really nice. So besides robotics, and besides new endoscopic approaches, AI and what the role AI is going to play in safety, you know, trying to be safer surgeon, and then providing interoperative guidance, for example, is really incredible. We're just sort of on that cusp of that revolution, and to see everyone at the table - industry and members - are just trying to figure out what's going on and then experts in the field all coalescing to discuss these issues was really exciting. But there's the content also across every service line. I'm always excited because we design our content and we did something actually unique the past year where we don't just ask our committee members to come up with ideas for the content for the sessions. We actually open it to the entire membership. So this wide-open process to say, "Send in your request." So we got bombarded and we love it, we want the ideas and suggestions from the membership to make sure we really cover everything. But it's hard to do that. But I think every specialty has a tremendous amount of sessions and video interactions and discussing complications and outcomes, reviews. I think it was really nice. And then of course, dear to our heart was also having content on wellness. And especially, DEI was a big focus for our society, most societies, but SAGES as well. And so that was really nice to have, between the keynote speaker, and some sessions specifically focused on diversity in the workplace, and how we can get better within organizational structures, but also in hospitals. Obviously, it was really nice to have a wide variety of speakers speak on these issues. So I thought that was one of the best content I've seen; I'm super psyched. And the hybrid format, you know, to be honest, millennials love it. I see people walking to one session, having an earbud in and listen to another session so they can get the whole content. I'm a little bit guilty of that. If I'm going to a board meeting in between, I'll be logging in and so I think it's very successful. It's a format that we really think will stay at least for awhile. People still value coming in and I think this interaction with experts is incredible. But it's to be on live session and hearing this and it's very, very valuable. So we'll see our numbers in terms of how many people logged in remotely and followed it versus the in-person presence. But it was pretty good. I can't complain about in [person]. We had we had rooms pretty full. The presidential address was a packed room, and that was great!
Ameer Farooq 36:46
For all our listeners, I think all the presidential sessions are actually free online on YouTube. Everybody needs to go listen to Dr. Feldman's talk, everybody needs to go listen to Marie King's talk; they're both really inspirational. You really left with some goosebumps on your arms after the session. So hats off to you and the rest of the SAGES community.
Patricia Sylla 37:06
It's gonna be hard to top that, but we will.
Ameer Farooq 37:08
So having said all that about what a wonderful meeting, what are your thoughts about where SAGES can go from here? It's a challenging time in the world. More broadly - culturally within North America - there are a lot of different things going on, inside and outside of surgery. What are your thoughts about where SAGES can go from here?
Patricia Sylla 37:33
I mean, we're human, the bottom line is, we have to continue to be true to our mission. The mission is continuing to innovate and collaborate, and especially education is really our main line. More than ever, especially through COVID, we've seen how valuable the educational offerings were; the attendance of webinars was off the hook. We have thousands and thousands of members, or not even SAGES members, nonmembers were tuning into those webinars and joining the SAGES Facebook groups. We saw that hunger, that thirst to not only be together, but to actually continue our education programs. And we know residency and fellows have been affected by COVID. So the main focus remains, really being quite razor-sharp focused on education, and really having the best education modules possible. So we're very concentrated on developing the Master's pathway, which will really help surgeons to enter the pathway and have the best educational experience along levels of competency or proficiency and expertise. And really, grouping all our educational material in one place will be much easier to navigate on our online platform, which is being deployed on Monday. So we're very excited about that and continuing to work on that. But the mission of pushing the boundaries, and innovation is going to be going more than ever, I think we're very focused on making sure that we stay on top of what's happening. The committees were formed to really tackle the issues of video-based assessment and what it will mean for us. So, we're developing these programs to be able to assess the competency of surgeons based on video assessment, how do you do that? So the technology is evolving in that direction, but we need to make sure that once these algorithms are in place and we can really better understand competency, and the question is, how do you implement training? So if somebody falls short of a particular score that has been validated, as you know, he's not competent. What next? We can't just stop there. So we're also working already now on coaching: How do we implement coaching? How is that going to look like, getting a report card, being then paired up with a proctor who's dedicated to coaching you through the process in an entrepreneurial way? So we want the 360-[degree] experience where SAGERS will be your resource, not only for your education, but for your assessment of competency and then remediation or enhancement of your skills and all in one hub. So this is sort of like the big picture and it does require being on the cutting edge of innovation. As those algorithms are being developed, and everybody worries about this in health care, you can't let data scientists decide where the algorithms are; they are relying on us to tell them what's important, what's not. We have to tell them "critical view of safety". What does that mean? For them it's just a data point, right? But for us, it's the art of what we do. It's the safety metrics. So we have to define what the metrics are, what the clinical endpoints are, what the valuable endpoints are. And so I think it's going to require a really very close collaboration with the data scientist to develop these algorithms in the best efficient, meaningful way. So I'm excited about that. I think very few societies are able to really merge efforts. And we have such a tradition of working collaboratively with industry. We don't want to be on a competitive basis. So data collection, for example, what does it look like? So when we launch CVS [Critical View of Safety] challenge, and asking people to donate videos so that we can refine those algorithms, what does that mean, for individual surgeons and members? We have a lot of work to figure out how we do this in an ethical fashion in a way that it's collaborative, and that data set can be used by others, not just by a limited group of people. So we have a lot of things to do. But that will really create pathways that I think are going to set the tone for the future. So we hope to remain on the upper edge of innovation, that's really a big focus of the society. And we have other focuses, but I think this is sort of what members are going to want to see from us. And of course, another big initiative for us that we're going to continue working very hard on is our big focus on DEI. So not only within the organization, but we're also very focused on making sure we are inclusive, and alert to how we deliver our care, especially minimally invasive surgery care to underserved populations. So a big focus I'm really excited about is, for example, from every educational content that we produce, we'll also take into account that DEI perspective. All those recommendations that we put out, are they also including underserved areas? What about vulnerable populations? Where do they fall on that spectrum? Can we do better to increase access to underserved areas? Every guideline that we produce, Does the evidence include those populations? Did we look closely at diabetic, African American males and how that particular bariatric procedure affect them in a way that is different than other populations, where you don't have as much data on them potentially. So it highlights some gaps in how we practise surgery, highlights disparities, that we want to bring back and incorporate in our recommendations and guidelines and research initiatives. So, you know, I'm big on research. So I don't want it to be just about expert recommendations and review the evidence; I want to create that evidence as well. So another focus, I think, in the next few years is going to also put in place a framework to do clinical collaborative trials. I'm really excited about what we can do with 7000 members, many of them want to be part of the solution, and are really open to collaborating in audits or registries or prospective trials. So I'm excited about the potential that we can do with our operations. We've done it in some ways, and I think it's time to scale that effort.
Ameer Farooq 43:16
I think one of the challenges for SAGES is, it was originally united around this concept of minimally invasive techniques and technology. And it's clear now that, for example, I go to a lot of sessions on robotics, and the reality in Canada is that we just don't have access, for example, to robotics. And so I think one of the challenges for SAGES really is going to be staying relevant to everyone who listens, because really SAGES now has a global audience. And I'd be remiss not to give a shout out to the SAGES "bot" who really has expanded the reach and really made SAGES a worldwide organization. People watch the YouTube videos from SAGES around the world. One of the things Dr. Mellinger was talking about last night at the social event was even perhaps introducing sort of that frugal innovation or reverse innovation where you actually learn from surgeons who are in less-resourced settings. And so I'm curious how that fits into SAGES, which in some ways has been viewed as the place to learn the most cutting-edge kind of techniques?
Patricia Sylla 44:21
That's an excellent question. I think we have a lot of work to do in that area. Our global surgery group is doing a lot of work in underserved areas, especially in South America, and now Africa. And I think we have a lot of work to do. So for example, a simple solution that they came up with was when they were teleproctoring they came up with a way to use Zoom to essentially be able to see 360, in the OR and laparoscopically and so others getting their surgeons and training their surgeons, they have that platform, which is low cost to be able to do the teleproctoring remotely. This is a solution that could only come about when you're actually on the ground, figuring out with low resources, how do you make it happen, and how do you scale that? So you're right, we have a lot to learn from other areas, low-resource areas to incorporate back into the framework to see, how do we do this and, especially, how do we scale it in areas that are underserved? So more to come.
Ameer Farooq 45:14
And I really have to ask, I know you have a family with kids and all of the responsibilities that accompany that, how do you make all that happen?
Patricia Sylla 45:24
I don't need a lot of sleep [laughs]. That's probably one. Although as I'm in my 40s now ... I could thrive on four hours of sleep a night for many, many years. Late in my 40s, I feel like, it's not quite the same. So you have to really take care of yourself. So I'm more aware now of my limitations than I ever was; before you kind of take your strength and energy for granted. But I think the other thing is support and being surrounded by people who really believe in you. I have a husband; he's a scientist, and I've been very lucky, his schedule is easier, he can spend more time at home, he's there before I get home at night. So there are ways that you can arrange your home life in a way that's compatible with your crazy work life. And then I think it's the passion. I mean, he's a passionate scientists, and it's kind of nice not to be talking about surgery all the time, which is good. And I'm passionate about what I do, so I think it sustains you, it really makes you thrive. And I think when you have that desire, that love for what you do, and that joy in what you do, it really gets you through a lot. And there's no question having a community of surgeons, I mean, I have mentors, but very valuable to me is having female mentors or mothers, because it's hard to relate with others when you're getting life advice or career advice from people who haven't gone through what you've gone through; it adds a layer of real tangible solutions. And so it's been really amazing, especially through SAGES, I've had the best mentors who really demonstrated themselves and given me the best advice to make it work and be a good mother and a good surgeon and a good friend and a good colleague, and especially a good educator, and really being able to do all of that.
Ameer Farooq 47:13
And we can't not talk about the fact that you're among a very rare group of female Black surgeons really at the top level of academic surgery. What was that experience like? Did you ever experience challenges during training on any of those types of fronts or levels and how did you overcome them?
Patricia Sylla 47:36
Yeah, I mean, we all have stories, and we talked about this. I mean, the first part of your talk was how you build resilience. And there are things that happen, that you decide, how you react in a moment can be different on how it impacts you later. So I think everyone has experiences that are less comfortable than others, and you learn from them. I think we navigate those complicated waters; we learn from them; it makes us tougher, and then you hope at some point you can talk about it. Especially when you become a leader, this is your opportunity to affect change. And this library of experiences from yourself, your own personal experience, and others takes a different meaning. Because once you're finally in a position of leadership, this is really when you can really affect significant change. And so we don't take these positions for granted. We're fully constantly aware of what we can do and finally affect. So it's a very privileged position to be in to finally implement programs and have those difficult conversations and really make sure that your faculty, your residents, your students feel that it's a safe space to discuss and to implement those changes, it's critical. But we've all had bad experiences. This is a reality of even being in New York. I mean, I think I've been relatively protected, being in a very diverse environment training in New York City. But still, it's not a protective factor. You have people with different backgrounds and biases and you can combat it with humour. That's what I did; my strategy was, we've got to turn this around really quick before it escalates. And we know now, that's not enough. You have to really bring attention to it and address it right there and then as much as possible, so people know there are things that you just don't do.
Ameer Farooq 49:36
It's such an important topic that we need to address within surgical training. What do you think we can do to make training programs more inclusive for everyone who wants to come and become a surgeon who has the requisite drive and the passion and the ability to do it? How do we make our institutions welcoming to everyone?
Patricia Sylla 49:56
I think perception is a lot. I think it's really important. And I think programs are going through a reckoning right now of, "What do we look like? What do we look like to our patients? What do we look like to our trainees and our faculty?" Especially if you think about recruiting and retaining, you have to really start paying attention to all those elements. And you have to embrace the change; you have to be committed to the change. We're moving away from just checking boxes, you know, "we have x percent of minorities, therefore, we're good, nothing else to do." It's really been conclusive at every level of decision-making, and in activities, and you have to be really reflecting on who's at the table making those decisions, how does it impact perception, visibility. I think every program should be going through this process of really internally looking and seeing where those gaps are. And I think once you start working on this with proper programs and training and dedicated, focused, intentional recruitment, to fill those gaps, it will become transparent to the applicant. They will see the change; they want to see that you're serious about diversity; they want to see that you're serious about advocating for these groups. And so it's essential. So I'm hopeful. I think every program is going through this; some are investing more resources than others, but it's happening. I think we've really pulled the Band Aid; the wound was always there, but I think we really are making a concerted effort as a society to really deal with those issues and create a better environment for the future.
Ameer Farooq 51:32
One of the questions we like to ask all of our guests at the end of the podcast is, if you could go back in time and give yourself advice as a chief resident, or maybe even as an early attending, having gone through what you've gone through, what would that advice be?
Patricia Sylla 51:50
Don't let people tell you that you can't do something that you're really passionate about. I have to be honest, I've always been known to be quite stubborn, and when people say no a bunch of times, there must be something to it [laughs]. But you shouldn't have to fight or convince people. I tell the residents all the time, "If you have a good idea or you have a good feeling about something you're truly passionate about, there will be people who will break it down, who will just tell you a million reasons why you can do it." And going back to your point about some of the comments when I was a resident of things could not do, because I was a female primarily, I don't know how the Black part came into it, but it probably was in an unconscious fashion, "you can't do this, you can't do that." You have to stick to it and it will take some effort, it will take some courage, it will take resilience; but, if you truly are passionate about something, there's really no excuse not to get out of your comfort zone and go and reach out for what you want. There are mentors outside of your institution, you know, through social media, you can connect with people who can empower you and enable you. There's really no limit if you really, truly believe in something. I was shy, but I think I overcame a lot of those by sort of bullying my way through things. It shouldn't be so hard. And so I think my advice is, if you're really passionate about something, there's a path to get it done.
Ameer Farooq 53:18
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.